Authors: Robyn Merkel-Walsh M.A., CCC-SLP & Sara Rosenfeld-Johnson M.S., CCC-SLP
This article, in the original form, was published in Advance Magazine for Speech Pathologists. The article has been expanded upon and revised with current Evidenced Based Practice.
Autism is a developmental disability that affects, often severely, a person's ability to communicate and socially interact with others. Autism Spectrum Disorder (ASD) impacts 1 of 68 children in the United States (CDC, 2015). In “cluster” states such as New Jersey, as many as 1 in 28 boys are affected. Autism Spectrum Disorders (ASD) is an umbrella term to include related disorders such as Asperger's Syndrome, Pervasive Developmental Disorder (PDD) and Kanner's Syndrome. The intensity of symptoms varies widely; however, all people on the spectrum display impairments in communication, social relationships and patterned behaviors. What is not as clearly understood, is the comorbidity of Oral Placement Disorder (OPD). There is acknowledgement that, at least in a subpopulation of children with autism, communicative deficits may instead stem from more basic motor and oral motor issues (Belmonte, Saxena-Chandhok , Cherian, Muneer, George & Karanth, 2013). Therefore, it is important for therapists to evaluate and treat not only the communication deficits with the ASD population, but also the oral sensory-motor deficits that many of these children present with.
Most individuals with autism are diagnosed by the age of three or younger, and the primary complaint is delayed language skills and/or the regression of language use (Wiggins, Baio & Rice, 2006). For example, parents often report that their child was able to say some words, but suddenly they stopped speaking and became socially withdrawn. At the same time, they began engaging in repetitive behaviors, their play skills regressed, and parents reported poor eye contact and limited socialization with others (CDC, 2015).
When a child is diagnosed with ASD, most likely, a Speech-Language Pathologist (SLP) will be called upon for an evaluation. It is imperative for therapists to look at not only receptive and expressive language, but oral motor skills, oral sensory-motor issues, feeding and motor planning in order to obtain global information that may be impacting the child's ability to communicate. Dr. Barry Prizant, a leader in the field of ASD, has indicated that there is increasing evidence that lack of speech and/or gestures in children with autism may be related to issues other than social-cognitive abilities. Prizant argues that clinical evidence suggests that motor speech impairments can be a significant factor inhibiting the development of speech in children with ASD (Prizant, Wetherby, Rubin & Laurent, 2010).
In clinical practice, the Speech-Language Pathologist needs to look at several areas in order to devise a treatment plan. This includes 1) sensory processing 2) structure and tone 3) pre-feeding skills 4) feeding skills 5) motor planning and 6) speech sound production.
Sensory processing is important to assess, as it relates to feeding and speech in children with ASD. Acceptance of touch to the face and oral cavity, as well as oral habits such as teeth grinding, mouthing objects and eating items other than foods (PICA) are critical to assess. Some children with ASD are over-responsive to sensory stimuli while others may be under-responsive. An over-responsive child may react to sounds in the kitchen and be distracted during meals, while an under-responsive child may seek pressure in the mouth by chewing on non-edible items (Overland & Merkel-Walsh, 2014).
Structure and tone must be assessed to rule out any comorbid factors that may be impeding feeding and speech. Children with autism may also present with issues such as: dysarthria, Orofacial Myofunctional Disorders, dental malocclusions, or Ankyloglossia. Low-tone occurs in approximately thirty percent of children with ASD (Bailey, 2013). Global hypotonia also occurs with ASD (NAN, 2015). Char Boshart (2015) has carefully designed an Ebook which outlines how to assess oral structures.
Pre-feeding skills are the underlying oral sensory-motor skills that are necessary for safe, effective, nutritive feeding (Overland & Merkel-Walsh, 2013). Morris & Klein (2010) and Overland & Merkel-Walsh, have written texts describing pre-feeding skills with careful detail.
A thorough feeding assessment is a team approach. In addition to the SLP, the feeding team may include the child’s pediatrician, nutritionist, gastroenterologist and/or otolaryngologist. It is important to determine if feeding challenges are organic or behavioral. Feeding disorders in children with ASD are often judged to be behavioral, when there may be medical and/or sensory-motor underpinnings. Most children with self-limited diets have feeding challenges that are multidimensional and are not purely behavioral (Roche, Eicher, Martorana, Berkowitz, Petronchak, Dziob & Vitello, 2011). Children with ASD often have sensory processing issues which impact feeding, but they may also have oral sensory-motor challenges that are related to deficits in pre-feeding skills. An SLP who diagnoses a feeding disorder in ASD must be sure to rule out any related medical etiology such as reflux or food allergies.
Motor planning disorders can also be comorbid with an ASD diagnosis. Childhood Apraxia of Speech (CAS), according to The American Speech-Language-Hearing Association, is a neurological childhood (pediatric) speech sound disorder in which the precision and consistency of movements underlying speech are impaired in the absence of neuromuscular deficits (e.g., abnormal reflexes, abnormal tone). CAS may occur as a result of known neurological impairment, in association with complex neurobehavioral disorders of known or unknown origin, or as an idiopathic neurogenic speech sound disorder. The core impairment in planning and/or programming spatiotemporal parameters of movement sequences results in errors in speech sound production and prosody (ASHA, 2007). In assessing a child with ASD, an SLP must determine if CAS could be a factor in a child being non-verbal. Experts in CAS, such as David Hammer and Deborah Hayden, have done extensive work in the diagnosis of CAS, and standardized measures such as The Kaufman Speech Praxis Test are available to clinicians to diagnose this disorder.
Finally, speech clarity is an important part of the assessment. There are standardized measures available, such as the Goldman-Fristoe Test of Articulation-2; however when assessing a child with ASD, standardized measures may prove challenging. There may also be children who cannot be tested because they are non-verbal. Therapists should not assume that cognition is severely impaired in a non-verbal child with ASD, because there may be coexisting oral-motor issues (Merkel-Walsh, 2014). This is why the aforementioned assessment tools are so important.
After a thorough assessment, the SLP can create a treatment plan that will incorporate: 1) oral sensory-motor based activities 2) feeding therapy 3) Oral Placement Therapy (OPT) and 4) speech sound production.
Oral sensory-motor based activities involve activities designed to regulate the sensory system, help stabilize postural stability, orient towards the midline and establish pre-feeding skills. Massage, vibration, and tactile stimulation methods are often used to stimulate oral postures, improve stability, and improve strength and dissociation (Morris & Klein, 2000). Deborah Beckman has a systematic approach to providing oral sensory-motor therapy called the Beckman Oro-facial Deep Tissue Release©. The protocol uses mechanical muscle responses, which are not mediated cognitively, to baseline the response to pressure and movement, range of movement, variety of movement, strength of movement and control of movement for the lips, cheeks, jaw, and tongue (Beckman, 2014). Therapeutic tools may also assist with sensory-motor and pre-feeding skills. For example, a Jiggler tool can be used to superimpose lip closure, the placement skill needed for bilabial sounds and spoon feeding. Massaging the lateral margins of the tongue can provoke lateralization which is important for safely handling a small bolus (Overland & Merkel-Walsh, 2013).
Therapeutic feeding techniques are necessary for those individuals who require supports to ensure a safe, effective, nutritive feeding (Overland, 2010). Therapeutic feeding involves postural supports, adaptive utensils and cups, placement of the food and supplemental techniques to assist in handling a bolus. It also involves careful consideration of food choices, especially with children on the autism spectrum. Establishing a home base diet is critical in diet-shaping and diet expansion (Overland & Merkel Walsh, 2013). Therapeutic feeding also considers nutrition needs and diet restrictions.
Oral Placement Therapy is a tactile approach to therapy for those individuals who cannot respond to look and me and say what I say. OPT is a modern extension of Phonetic Placement Therapy (Van Riper, 1954) and The Feedback Model (Mysak, 1971). It is based on a very common sequence (Young and Hawk, 1955; Van Riper, 1978). Merkel-Walsh and Roy-Hill (2014) presented this concept at the ASHA Convention:
Facilitate speech movement with the assistance of a therapy tool (ex. horn, tongue depressor) or a tactile-kinesthetic facilitation technique (ex. PROMPT facial cue);
Facilitate speech movement without the therapy tool and/or tactile-kinesthetic technique (cue fading);
Immediately transition movement into speech with and without therapy tools and/or tactile-kinesthetic techniques.
Speech sound production should always proceed oral sensory-motor and OPT tasks. Speech tasks may involve repetition of target words, and may involve tactile cueing such as the PROMPT method (Prompts for Restructuring Oral Musculature Phonetic Targets). PROMPT has been found useful for children with ASD, (Rogers, Hayden, Hepburn, S., Charlifue-Smith, Hall & Hayes, A. 2006). PROMPT is a positive treatment method, as it provides cues for placement for children who cannot easily imitate oral placements for sound production. PROMPT can be used in conjunction with language goals.
Once a plan is established and an OPT plan is created, therapists are often challenged by service delivery models, since individuals with ASD often present with challenging behaviors including: self- stimulatory behaviors (e.g. hand flapping or spinning), aggression, non-compliance, work avoidance and inability to attend to task. Since there are many theories on service delivery models in autism, therapists must decide which model best suits their treatment style, and which models are based on research and evidence based. With some background on oral-motor therapy and OPT, therapists know that the child must be seated appropriately in order to gain stability and appropriate positioning for the therapy to be successful. This often presents as a challenge with this population; however with help from ASD experts, it is quite easy to incorporate oral motor and OPT techniques into a therapy plan.
Greenspan, Wetherby and Prizant are advocates of language developing through play schemas in the natural setting. Floor time, modeling and hands-on life experiences are critical in this “child centered” model. Typical natural settings include the home, the park and the grocery store. This approach follows the child's "lead", the direction the child wants to go. The adult engages the child in pleasurable activities with reciprocal play and communicative exchange, so that the activity in itself is reinforcement for the child. The therapist judges what the child wants to do based on non-verbal and verbal cues. This is the basis of the SCERTS model. “SC” - Social Communication – the development of spontaneous, functional communication, emotional expression, and secure and trusting relationships with children and adults; “ER” - Emotional Regulation - the development of the ability to maintain a well-regulated emotional state to cope with everyday stress, and to be most available for learning and interacting; “TS” – Transactional Support – the development and implementation of supports to help partners respond to the child’s needs and interests, modify and adapt the environment, and provide tools to enhance learning (e.g., picture communication, written schedules, and sensory supports). Specific plans are also developed to provide educational and emotional support to families and to foster teamwork among professionals (Prizant, Wetherby, Rubin & Laurent, 2007).
Though the SCERTS is a wonderful model for therapy, the challenge in using this approach with oral sensory-motor and OPT programs is that the therapy is definitely led by the therapist, the client does not select the activities or tools, because the therapist knows what activities are required to improve a certain muscle-memory based skill (Merkel-Walsh, 2014). The treating SLP must balance the structure needed for OPT programs with a model that fosters a reciprocal communication exchange.
Applied Behavioral Analysis (ABA) is a method of behavioral intervention developed by Ivan Lovaas PhD and Tristan Smith PhD. It consists of teaching skills by breaking them down into small steps, while rewarding the correct responses. It is data driven and quite intensive. ABA is often associated with Discrete Trial Teaching (DTT) which uses the instruction-prompt-response-reward method to help people on the spectrum complete complex tasks. The ABA method has the most empirical research to date to show progress in children on the autism spectrum (CAN, 2005). This approach is better suited to oral-motor therapy, since OPT activities are broken down into small specific steps and have preset mastery levels, such a Bite Blocks, which have a 15 second criteria for mastery. OPT tasks can easily be written into short term objectives (STO) which are the basis of program books for ABA programs. OPT progress can be easily charted and graphed to track progress.
Graph provided by www.rethinkfirst.com.
Therapists do not have to choose between these two models; both principles can be applied if therapy sessions are carefully planned. A challenge in following the child-centered approach is that OPT programs have pre-established hierarchies and set requirements for mastery or success; however, one must consider that therapy must be rewarding in order for the child to engage. Children on the spectrum will need consistent, highly-motivating tangible reinforcers to engage in OPT. In addition, the sessions need to be language oriented as the main goal is oral communication.
With these principles in mind, here are general parameters in structuring Oral Placement Therapy with children presenting with ASD:
• Create a calming environment ensuring that lighting and sound have been considered in relation to sensory processing issues. Meta-music, a lava lamp, or concentration tapes can all help make the session more calming and rewarding. Consult with an Occupational Therapist if a child with ASD presents with very intense sensory dysregulation.
• Select an appropriate setting that encourages 90 degree angles in the hips, knees and ankles. Make sure the feet are on the floor or flat on an elevated surface, such as the foot rest of a high chair. You may use dycem on the chair so the child does not slide, or may need additional weighted items, such as a rice bag across the lap or a weighted vest, to give additional sensory input. If this is not possible due to out of seat behavior, a Behaviorist will need to intervene prior to therapy sessions and help the SLP with a behavior plan and/or use of alternative seating such as a bean bag chair, swing and or a ball pit.
• Create a picture schedule booklet for the client or schedule board from start to end with every activity and built in breaks for gross and sensory-motor play. Ensure that you are using favorite items, sound activities toys, music, and sensory based activities for free play on breaks. This builds in Greenspan's philosophies while keeping within the structured parameters of an ABA format.
• In coordination with an ABA Therapist/Behaviorist, create a token board with a set reward for positive work. For example, 5 pennies can result in a pretzel or squish toy. It also helps to take a photo of the child engaged in the target behavior, such as sitting in a chair with "quiet hands.” Verbalize the target behavior consistently and avoid talking about the negative behavior such as "no spitting" or "stop that." Use positive verbal cues such as, "good sitting with hands down.”
• When using food reinforcers, coordinate this with feeding therapy. For example, a specific placement of a strip to the molars, as where the food is placed in the mouth impacts the skills used to break it down. Use a highly desirable drink, such as fruit juice, with a target straw from the TalkTools® Hierarchy.
• A therapy protocol should always incorporate sensory activities (Sensory Bean Bags, vibration, massage, ZVibe), jaw activities (Bite Blocks, Jaw Exerciser, Chewy Tube etc.), respiration and phonation activities (Horns, bubbles) and additional OPT activities as needed (Lip Press, etc.). The session should always include sound drills, word imitation (verbal ims) and/or play with targeted words embedded within the structured activity.
• For many kids with ASD, the speech therapist will be involved with sensory-based food tasting programs which can be presented in a discreet trial teaching (DTT) model. First, the child needs to tolerate the new food in their proximity, then touch it, smell it, tolerate it near the mouth, kiss it/tongue touch, hold it in the mouth, chew it and swallow. These steps need to be broken down into small tasks that are highly reinforced.
• Create an OPT book with specific therapy and chart notes, so that the work is done at home and at school/clinic. The therapist must train the parent, or in some cases the babysitter or ABA therapist, so that the exercises are done daily. This is not to say that an ABA therapist should be performing speech therapy, but rather facilitate progress by practicing specifically assigned homework. In some cases, challenging behaviors are much easier for a ABA therapist than for the parent. In addition, parents can videotape sessions to follow at home. Video modeling is a very common procedure in ABA programs.
• Since the main goal is expressive communication, it is imperative that the therapist recognizes the clients strengths in terms of jaw-lip-tongue dissociation and planes of movement as taught by Debra Hayden's PROMPT System Hierarchy, Nancy Kaufman’s “Kaufman Praxis Level 1” and Lori Overland's/Sara Rosenfeld-Johnson's oral motor developmental norms references. This will help the speech therapist select the first words for drill and repetition in order to translate muscle-motor memory into speech production. For example, if the child's lip closure is a goal, and he/she is working on TalkTools® horn level 1, simple CV, VCV, VC words with picture cards should be used to elicit productions such as: me, bee, apple (ae-po), up and so forth. The words should be practiced in every session with the help of facial cues (PROMPT), and lip reading cues to 80% mastery. When this occurs, the therapist can then fade cues and move to higher level targets such as CVC forms.
• To evoke new productions spontaneously, David Hammer, an expert in the field of apraxia, recommends use of repetitive games and toys within each session. For example, if target words are in/out use a simple activity, such as small animals that go in and out of a paper towel tube, and repeat this each session so that the client can predict what utterances are expected. Prediction of outcome reduces anxiety and also follows along with Dr. Edythe Strand's research on the need for repetition in order to solidify a motor plan.
In summary, OPT for children with ASD is an essential part of their speech therapy program in addition to pragmatics, language, sensory integration and total communication. While engaging children with ASD may be challenging, if speech therapists follow the lead of experts in the field of autism, OPT is actually quite easy to deliver as long as the therapist combines the principles of behavior modification with natural language development. Since OPT hierarchies are very task oriented and data driven, (e.g., each TalkTools® horn has a pre-established criteria for mastery), therapists can present activities in specific sequences with consistent positive reinforcers which is in line with the experts suggestions for systematically teaching target behaviors in an ABA format, while the SCERTS approach opens pathways for carryover and language acquisition with improved speech clarity.
Click here to learn more about the course Robyn Merkel-Walsh teaches on Autism & OPT
Robyn Merkel-Walsh MA, CCC-SLP is a speech pathologist with over 20 years of experience in both the Ridgefield Public Schools, and in her private practice located in Bergen County, NJ. She is the author of The Smile Program, A Sensory Motor Approach to Feeding, and other educational materials. Robyn is a certified TalkTools Instructor on Tongue Thrust, Autism and Oral Placement Therapy. Robyn is the acting chair of the Oral Motor Institute. She can be reached at email@example.com.
Sara Rosenfeld-Johnson MS, CCC-SLP is the founder of Innovative Therapists International, and TalkTools® based in Charleston, South Carolina. She is the author of Oral Placement Therapy (OPT) for Speech Clarity and Feeding, The HOMEWORK Book, Assessment and Treatment of the Jaw, OPT for /s/ and /z/ as well as many other education materials. Sara specializes in assessment and treatment of motor speech and feeding disorders. She is a national and international speaker on the topic of Oral Placement Therapy. She can be reached at firstname.lastname@example.org.
Thanks to Rethink for providing the graph above.
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